Water precautions in children with tympanostomy tubes.

PURPOSE: The necessity and effectiveness of taking precautions around water with children who have tympanostomy tubes is a source of some controversy among otolaryngologists. This study was undertaken to survey the practice standards of otolaryngologists treating these children. MATERIALS AND METHODS: A total of 1,266 board-certified otolaryngologists practicing (mean 14.8 years in practice) in the southern and eastern United States were surveyed to determine current recommendations. RESULTS: Among those surveyed, 13.1% forbid children with tympanostomy tubes from swimming, whereas 3.1% feel that no water precautions are needed. Limitations are placed in the depth of swimming by 68% and the type of swimming water by 18%. The most commonly recommended form of protection is the use of ear plugs, which is favored by 53.4%. Liberalization of recommendations concerning the need for water precautions was noted by 79% of respondents who cited personal experience as the single most influential factor. An overwhelming percentage of respondents indicated they would be willing to alter their current practice based on new information generated from a clinical trial. CONCLUSION: This survey demonstrates that diversity of opinion does exist among otolaryngologists relative to their recommendations for water precautions after placement of tympanostomy tubes. This survey demonstrates the need for a prospective randomized clinical trial designed to address this issue.     

Swimming and tympanostomy tubes: a prospective study

To prevent ear infection, many physicians advise their patients to avoid water after insertion of tympanostomy tubes. This advice is a logical extension of the supposition that contaminated water entering the middle ear through the tube may cause an infection. While tympanostomy tubes have been in widespread use for over 30 years, very few prospective clinical trials have evaluated their use while swimming. This study evaluated 85 patients with tympanostomy tubes divided into three groups: swimming without earplugs, swimming with earplugs, and no swimming. The infection rates were 16%, 30%, and 30% in the three groups, respectively. We conclude that swimming without earplugs does not result in an increased incidence of middle ear infections.     

Post-myringotomy care: a prospective study

Children with tympanostomy tubes have always been considered somewhat handicapped in regard to swimming and bathing. Their parents had to maintain constant surveillance to prevent then from getting water in their ears. A prospective study involving more than 1,000 children was conducted between June 1981 and August 1982 on two groups of randomly selected patients to determine the prevalence of suppurative otitis media and its relationship to bathing and swimming. One group had to follow strict rules to prevent water entering the ear (bathing caps, earplugs) whereas the other group was allowed to bathe and swim without any precaution upon the condition of using a polymyxin B/gramicidin ear drop combination at bedtime on the day they swam. The study shows no increase in prevalence of suppurative otitis media in the "open canal" group as compared to the "closed canal" group. Furthermore, the monthly distribution of infections shows a relatively evan distribution throughout the year. This study implies that swimming and bathing are safe for the vast majority of children with tympanostomy tubes and thus simplifies enormously the post-myringotomy care for the child, the parents, and the physician.     

Guidelines for the treatment of tympanostomy tube otorrhea

Treatment of tympanostomy tube otorrhea has evolved with numerous studies demonstrating the superiority of topical therapy in the form of eardrops over systemic antibiotic therapy. Many physicians have been concerned about ototoxicity with antibiotic eardrops because several ototopical agents have a risk of vestibular and cochlear damage, which may be permanent. An expert round table of pediatric and general otolaryngologists, pediatricians, and family physicians met in Quebec City in May 2004 to develop practical Canadian guidelines for the safe treatment of tympanostomy tube otorrhea. The recommendations and guidelines are outlined.     

A meta-analysis of swimming and water precautions

OBJECTIVE: To reconcile conflicting reports concerning the incidence of otorrhea in children with tympanostomy tubes who swim without ear protection. STUDY SELECTION: Articles were identified by MEDLINE search, Current Contents, and references from review articles, textbook chapters, and retrieved reports. Controlled trials of water precautions following tympanostomy tube placement were selected by independent observers and scored on 10 measures of study validity. Five English-language articles met all inclusion criteria. DATA EXTRACTION: Data were abstracted for an endpoint of otorrhea following swimming without ear protection with a minimum follow-up of 6 weeks. DATA SYNTHESIS: Pooled analysis of 619 children revealed a rate difference of -5.04 (95% confidence interval [CI], -11.62 to 1.54). No significant difference in the incidence of otorrhea was noted between patients who swam without ear protection and nonswimmers. CONCLUSION: There is no increase in incidence of otorrhea in children who swim without ear protection compared with children who do not swim following tympanostomy tube placement.     

Passive smoking after tympanostomy and risk of recurrent acute otitis media

OBJECTIVE: Exposure to environmental tobacco smoke has been reported to be a risk factor for childhood otitis media. The effect of parental smoking on the risk of otitis media after the insertion of tympanostomy tubes is unknown. We evaluated the effect of parental smoking on the risk of recurrent otitis media in children who had received tympanostomy tubes. METHODS: We enrolled 217 children aged 1-4 years who underwent insertion of tympanostomy tubes because of middle ear disease. The children were followed-up for 12 months. Otitis media episodes were recorded in patient diaries by primary care physicians. Parental smoking habits were assessed by a questionnaire at the start of the trial and after the 12 month follow-up had ended. The main outcome measure was risk of recurrent otitis media as defined by four or more otitis media episodes after tympanostomy. Altogether 198 children completed the follow-up. RESULTS: Maternal smoking was associated with a highly increased risk of recurrent acute otitis media (OR 4.15, 95% CI 1.45-11.9) after the insertion of tympanostomy tubes. CONCLUSION: Exposure to passive smoking is associated with four-fold risk of recurrent otitis media after tympanostomy. This finding should be used to encourage parents to stop smoking even after the insertion of tympanostomy tubes to their children.     

Dr. Miller Goes to Washington: You Should,Too

Otolaryngologists, like most physicians, tend to avoid local, state, and national politics for a variety of reasons. Although physicians and their patients are frequently affected by policies made in these political arenas, physicians tend to avoid active participation because of inexperience, lack of time, lack of knowledge about ways to influence policy development, and a general distaste for the political process. Otolaryngologists need to participate in the process to ensure that their particular perspectives and concerns are heard. However, otolaryngologists also need to look beyond their personal or specialty interests to influence the broader health care debate. Before we are specialists, we are first physicians who have a fiduciary responsibility to mankind (our patients) to improve the health care system for all Americans. We have a moral and ethical obligation to address, influence, and support health care beyond the specialty level. Health policy developed in an absence of physician input is missing the insight of expertise and experience.     

Assessment of the consensus about tonsillectomy and/or adenoidectomy among pediatricians and otolaryngologists

Background

Several recent publications have shown that the current indications for tonsillectomy and/or adenoidectomy (T&A) in children vary considerably between and even within countries. The objective of our study is to present statistically valid information to surgeons and pediatricians, primary care physicians, and family physicians as key referral channels to the operation, whether there is consensus between pediatricians and otolaryngologists regarding the appropriateness of T&A.

Methods

Six academic pediatricians and six otolaryngologists participated in the study. After otolaryngologists visited 200 patients, the cases were referred to a pediatrician who also visited the patients independently on the same day pre-operatively. They ranked the appropriateness of T&A on a numerical Likert scale from 0 (never indicated) to 9 (always indicated) in a questionnaire.

Results

Overall, 200 (102 boys and 98 girls) children with a mean age of 6.1 ± 5.6 were enrolled in this study. Otolaryngologists and Pediatricians had agreed about the history of tonsillitis attacks in the previous 6 months and previous year. The patients provided them with the same history. The agreement between otolaryngologists and pediatrician's views about T&A was poor.

Conclusions

This study can serve as an initial warning in developing a national community-based working group to prepare a transparent local guideline regarding T&A indications. More attention should focused the role of pediatricians, primary care physicians, and family physicians for more follow up and determining which patients will eventually need T&A.     

Opening Plugged Tympanostomy Tubes

Objective To determine the most effective solvents for dissolving plugged tympanostomy tubes. Study Design In vitro laboratory study. Methods Twelve solvents (including ototopical antibiotics and water) were applied to fluoroplastic tympanostomy tubes (n = 260) plugged with dried mucoid middle ear effusion in an ear canal–tympanic membrane model. Time to clearance of the tympanostomy tubes was both visually and tympanometrically determined. Results Vinegar (P = .0030) and hyaluronidase solutions (P = .0030) were significantly better solvents than water. Conclusion Vinegar and hyaluronidase solutions are more likely to clear plugged tympanostomy tubes than water and ototopical antibiotics, but vinegar is the preferred solution because of its known relative safety for use in the ear.     

Comparison of performance by otolaryngologists, pediatricians, and general practioners on an otoendoscopic diagnostic video examination

OBJECTIVE: To compare the performance of United States, South African, and Greek otolaryngologists, pediatricians, and general practitioners in recognizing the otoscopic examination findings of acute otitis media (AOM) and otitis media with effusion (OME) as presented in an otoendoscopic video evaluation test. DESIGN/SUBJECTS: Otolaryngologists, pediatricians, and general practitioners from the United States (n = 273, 2190, and 360 respectively), South Africa (n = 36, 36, and 206), and Greece (n = 58, 115, and 126) viewed nine different video-recorded otoscopic examinations, including pneumatic otoscopy of tympanic membranes. The ability to differentiate AOM, OME, and normal was ascertained. RESULTS: Overall, the average +/- standard deviation correct diagnosis on the otoscopic video exam by otolaryngologists was superior to pediatricians and general practitioners in all three countries: from the United States, it was 74 +/- 16% for otolaryngologists versus 51 +/- 11% for pediatricians (p < 0.000l) and 46+/-21% for general practitioners (p < 0.0001); from South Africa, it was 72 +/- 16% versus 53 +/- 21% (p = 0.16) and 47 +/- 19% (p = 0.002); and from Greece, it was 61 +/- 15% versus 36 +/- 12% (p < 0.003) and 39 +/- 10% (p = 0.009). CONCLUSIONS: A video-based otoscopy examination test may be a useful tool for evaluation of otoscopy-based diagnostic skills. Otolaryngologists performed significantly better than pediatricians in differentiating AOM, OME, and normal in such a test described here. However, all specialists who examine patients with AOM or OME may benefit from viewing video otoscopies to improve diagnostic accuracy.     

Predictors of chronic suppurative otitis media in children

OBJECTIVE: To determine which factors predict development of chronic suppurative otitis media (CSOM) in children. DESIGN: Case-control study, with univariate and multivariate logistic regression analysis applied to determine which factors independently predict CSOM. SUBJECTS: Prognostic factors for CSOM were identified in (1) 100 children with CSOM and 161 controls aged 1 to 12 years and (2) 83 children who developed CSOM in the presence of a tympanostomy tube and 136 children with tympanostomy tubes who did not develop CSOM. RESULTS: Independent predictors for CSOM were previous tympanostomy tube insertion (odds ratio [OR], 121.4 [95% confidence interval {CI}, 38.9-379.3]); having had more than 3 upper respiratory tract infections in the past 6 months (OR, 12.2 [95% CI, 3.5-42.3]); having parents with a low education level (OR, 14.1 [95% CI, 2.9-68.6]); and having older siblings (OR, 4.4 [95% CI, 1.6-12.6]). Independent predictors for CSOM after tympanostomy tube insertion were having experienced more than 3 episodes of otitis media in the past year (OR, 4.9 [95% CI, 2.2-11.0]; attending day care (OR, 3.6 [95% CI, 1.7-7.8]); and having older siblings (OR, 2.6 [95% CI, 1.2-5.5]). CONCLUSIONS: Treatment with tympanostomy tubes is the most important prognostic factor for CSOM in children. In children who are being treated with tympanostomy tubes for persistent middle ear effusion, the most important prognostic factor for CSOM is a history of recurrent episodes of acute otitis media. This information should be taken into consideration and discussed with parents when considering insertion of tympanostomy tubes in children.     

A case study of an emerging community-based early hearing detection and intervention program: part II. Team building with otolaryngologists and pediatricians using a survey approach

PURPOSE: Physicians are vital team members of early hearing detection and intervention programs (EHDIPs), particularly in encouraging parents to comply with recommendations for follow-up services for their infants in universal newborn hearing screening programs (UNHSPs). This study describes a survey approach to help audiologists partner with otolaryngologists and pediatricians in EHDIPs. METHOD: We developed and mailed a 19-item questionnaire to all 12 otolaryngologists and 66 pediatricians potentially involved in a community-based EHDIP. The questionnaire assessed respondents' demographic data and knowledge of, experiences with, and attitudes toward the service-delivery continuum of UNHSPs. RESULTS: The overall response rate was 45%; all 12 otolaryngologists responded (100%; data from 7 were analyzed), and 23 pediatricians responded (34.8%; all were analyzed). Generally, they were positive toward and knowledgeable about UNHSPs and believed that (a) parent/infant bonding is unaffected by screening, (b) hearing reevaluations following medical services are important, (c) audiologists perform their role adequately, (d) it is important that hearing losses be identified and interventions begun before infants reach 6 months of age, (e) UNHSPs deserve funding, and (f) their role is important, but the physicians also wanted improvements in parent education and referral/follow-ups. CONCLUSION: The survey method was effective in identifying participating physicians' informational needs and attitudes toward UNHSPs, and in designing outreach programs for them.     

Swimming unprotected with long-shafted middle ear ventilation tubes

Patients, parents, and physicians are all concerned about the risks of swimming unprotected with middle ear ventilation tubes. The risks have not previously been carefully quantified or correlated with the degree of swimming activity. In this study, 53 children with tympanometrically proven patent long-shafted tubes were allowed to swim unprotected. They suffered six middle ear infections that were clearly caused by swimming. Five of these infections occurred in divers. The rate of infections for divers was approximately one per 100 days of swimming activity. The rate for non-divers was approximately one per 600 days. Unprotected swimming was well accepted by almost all parents and patients. The need for earplugs for all children who swim with long-shafted ventilation tubes is questioned.     

Intracranial complications of acute and chronic infectious ear disease: A problem still with us.

Among 334,884 admissions to the North Carolina Baptist Hospital from 1963 through 1982, 100 patients had central nervous system (CNS) complications of middle ear disease. The complications occurred predominantly in young patients, 85 of the 100 being less than 20 years of age. Meningitis occurred in 76 patients; the acute form was more prevalent (63 cases). The less common nonmeningitic complications included brain abscess (n=6), effusion (n=5), lateral sinus thrombosis (n=5), otitic hydrocephalus (n=5), and empyema (n=3). Overall mortality was 10%. One patient with brain abscess died; 9 of the 76 patients with meningitis died (12%), with 4 of those deaths occurring among the 13 patients with chronic meningitis (31%). Because these complications have declined markedly since the advent of antibiotics, many contemporary otolaryngologists have been unexposed to these complications. However, as this series shows, they do still occur, their natural history remains the same, and the resulting mortality is still alarmingly high. A plea is made for otolaryngologists to maintain an awareness of these complications and to work with pediatricians and neurosurgeons for the best team care of patients with CNS complications of middle ear disease.     

Tympanostomy tubes for otitis media: quality-of-life improvement for children and parents

We measured quality of life issues for both children and their parents on the premise that parental quality of life should be an aspect of cost-effectiveness in otitis media treatment. The patients were less than 18 years of age and had had myringotomy with tube insertion at the head and neck surgery department of a large health maintenance organization. Quality of life for patients, parents, and caregivers was evaluated by telephone survey of parents or caregivers and by retrospective chart review of the number of pre- and postoperative healthcare visits and antibiotic usage. Chart review showed a significant postoperative reduction in the number of clinic visits and in use of antibiotic drugs after insertion of tympanostomy tubes. Improved postoperative hearing was noted, and tympanostomy tube insertion was shown to be safe. The chart-review cost analysis showed that tympanostomy tube insertion is a cost-effective treatment for otitis media in children, and the telephone survey results showed that it improves quality of life for children and their parents or other caregivers.     

What Your Colleagues Think of Tympanostomy Tubes—28 Years Later

Objective: Assess the changing opinions of otolaryngologists about tympanostomy tubes, including indications, tube material and shape and size, placement sites, and complications. Study Design: Crosssectional survey, compared to the same survey done 28 years earlier. Method: Questionnaires mailed to the 441 active fellows and 86 candidates of the Triological Society. Response rate 69.3%. Results: The preference for polyethylene has decreased from 75% to 13% of respondents. Preferred insertion sites are more anterior. The proportion of respondents who have seen a permanent perforation as a consequence has increased from 26% to 93%. The proportion of respondents who have seen a tube-attributable cholesteatoma has increased from 8% to 38%. The average tube duration has increased from 4 months to 18 months. Teflon and Silastic are now the materials most often used. As 28 years earlier, about 19% of patients get a subsequent tympanostomy tube. Anesthetics most commonly used now are general or topical phenol. Conclusion: The consensus on several aspects of tympanostomy tubes has changed during 28 years. Controversy continues about the indications for using tubes. Although not a not cure-all for otitis media, tympanostomy tubes have proved useful.     

Medial migration of tympanostomy tubes: an overlooked complication

BACKGROUND: Frequently encountered complications associated with tympanostomy tube placement have been well documented and are globally recognized. The medial migration of tympanostomy tubes into the middle ear space is a rare complication for which pathogenesis, natural history, and management have not been clearly delineated. OBJECTIVE: To describe our experience with the medial migration of tympanostomy tubes into the middle ear space. To propose a simple classification system and define management recommendations. METHODS: A retrospective chart review of all patients with medial tube migration seen in a Pediatric Otolaryngology practice at a tertiary care university hospital between 1995 and 2005. RESULTS: Six pediatric patients (ages 3-19) were found to have seven tympanostomy tubes within the middle ear space at various intervals following tube placement. One patient had a migrated tympanostomy tube deep to a large myringotomy incision. Five patients (six ears) had migrated tubes medial to intact, healed tympanic membranes. Fifty percent of the patients had symptoms attributable to the migrated tube. All six patients underwent middle ear exploration with successful removal of the migrated tube. CONCLUSIONS: This process can be defined as primary, when the tympanostomy tube migrates due to a technical error, or secondary, when the tube is initially seen in the correct position but is later found medial to a healed, intact tympanic membrane. Medial migration is apparently independent of tube type and can occur at various intervals after placement. The process of secondary migration is most likely multifactorial but may in part be the result of persistent negative middle ear pressure. Migrated tubes should be removed surgically unless contraindicated.     

Deficiencies of cross-training between pediatrics and otolaryngology: a survey of specialists in Canada

OBJECTIVE: Conditions relating to the ear, nose and throat are very frequent problems encountered by general pediatricians. Similarly, a major percentage of patients seen and operated on by the general otolaryngologist are of the pediatric age group. The pilot study demonstrated that pediatric program directors of both specialties in Canada have identified a deficiency of cross-training and desire the need for more cross-training. The aim of this study was to survey practicing physicians of both specialties for their input. METHODS: Surveys were sent to a large cross-section of pediatricians and otolaryngologists in Canada. They were asked to complete a questionnaire relating to their training experience, their desired training, important topics and general comments. Demographic data were collected including generalist versus sub-specialist, the year that residency was completed and country of training. Results were tabulated and analyzed. RESULTS: The response rate was high, being 70.6% and 76.2% for pediatricians and otolaryngologists, respectively. One hundred percent of pediatricians indicated that formal training by otolaryngologists was necessary, while 95% of otolaryngologists indicate a need for formal training by pediatricians during residency. Pediatricians desire more training using all three educational venues, namely lectures, clinics and rotations. While they are receiving lectures more often, they indicate that clinics are the most important mode of education. Otolaryngologists desire more formal training by pediatricians in the areas of lectures and clinics. They indicate the most important mode of education is lectures. There was no significant difference between generalists and sub-specialists or based on country of training for either group. There is some indication, in both specialties, of an increase of cross-training occurring within the past five years. CONCLUSIONS: This study has shown that there is a perceived deficiency of cross-training between the two specialties. Both pediatricians and otolaryngologists have indicated that they need more formal cross-training. This is a very important area to address, as this study relates directly to the optimum health of children in Canada and worldwide.     

Water precautions and tympanostomy tubes: a randomized, controlled trial

OBJECTIVES/HYPOTHESIS: The objective was to determine whether there is an increased incidence of otorrhea in young children with tympanostomy tubes who swim and bathe without water precautions as compared with children who use water precautions in the form of ear plugs. STUDY DESIGN: Prospective, randomized, investigator-blinded, controlled trial. METHODS: Two hundred one children (age range, 6 mo-6 y) who had undergone bilateral myringotomy and tube insertion were randomly assigned into one of two groups: swimming and bathing with or without ear plugs. Children were seen monthly for 1 year and whenever there was intercurrent otorrhea. RESULTS: Ninety children with and 82 children without ear plugs returned for at least one follow-up visit. Mean (SD) duration of follow-up was 9.4 (4.1) months for the children with ear plugs and 9.1 (4.4) months for the children without ear plugs. Forty-two children (47%) who wore ear plugs developed at least one episode of otorrhea, as compared with 46 (56%) who did not use ear plugs (logistic regression adjusting for stratification variables, P = .21). The mean (SD) rate of otorrhea per month was 0.07 (0.31) for the children who wore ear plugs as compared with 0.10 (0.31) for the children who did not wear ear plugs (Poisson regression adjusting for stratification variables, P = .05). CONCLUSION: There is a small but statistically significant increase in the rate of otorrhea in young children who swim and bathe without the use of ear plugs as compared with children who use ear plugs. Because the clinical impact of using ear plugs is small, their routine use may be unnecessary.